StudyLoop

Nurs 422 SBAR (Situation, Background, Assessment, Recommendations)

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by

luna
in

 

 

Student Name:                                      Date of Encounter:

 

 

Situation
Patient Initials:  
Patient Age:  
Date of Admission:  
Reason for Admission & Admission Dx:  
Current Diagnoses:  
Allergies:  
Gender (Include gender identity/pronouns if applicable)  
Current Medications (only psychopharmacologic agents)

·      Generic name

·      Brand name

·      Strength

·      Form (tablet, capsule, suspension, etc)

·      Route

·      Frequency

·      Reason

·      Any other pertinent medication information

  
Other medical conditions:  
Current Symptoms:  
Diet/Nutrition Information

·      Current weight

·      Current height

·      Special diet (if yes, explain)

  
Recent labs:  
Current psychotherapy and type if known (CBT, Interpersonal, Group, etc)  
Background
Patient history:

·      Past psychiatric history:

·      Past psychiatric hospitalizations:

·      Past psychiatric medication trials:

·      Past psychiatric non-medication treatments:

·      Any known family psychiatric history:

  
Social History:

Highest grade completed

Learning disabilities

Living situation:

·      What type of dwelling

·      Homeless?

·      Who does patient live with?

·      Single/Married/Divorced?

·      Children

Occupation:

Employed (Full-time, part-time, unemployed):

Legal issues (past and current):

Financial issues:

Substance Use (see below)

·      Illicit substance use (list substances, how much, how long, when was last use)

·      Alcohol use (list type, how much, how long, last use)

·      Caffeine use (list type, how much, how long, when was last use)

·      Any past inpatient/outpatient treatments for any substance use/abuse

 

  
Assessment
Include the top 3 priorities or risks for your patient. These could include something that they are at risk for (suicide, eloping, overdosing, aggression, etc) or they could include priorities/risks based on social factors now or upon discharge.
Priority/Risk 1:

(List priority issue, why it is a risk/issue, and why it needs addressed)

  
Priority/Risk 2:

(List priority issue, why it is a risk/issue, and why it needs addressed)

  
Priority/Risk 3:

(List priority issue, why it is a risk/issue, and why it needs addressed)

  
Recommendations
List nursing recommendations and interventions that will address the priority/risks above. Provide a scholarly source for each recommendation. You can use UpToDate or course materials. Each should include at least 1 in-text citation and a corresponding reference. Examples of recommendations include referrals and/or nursing interventions.
Recommendation for Priority/Risk 1:

 

  
Recommendation for Priority/Risk 2:

 

  
Recommendation for Priority/Risk 3:

 

  

 

References